Failure to Provide Timely Pressure Ulcer Assessment and Prevention
Penalty
Summary
Surveyors identified that the facility failed to provide necessary pressure ulcer care and prevention for three residents with or at risk for pressure injuries. For one resident with quadriplegia and multiple pressure injuries, the facility did not perform a comprehensive assessment of the resident's wounds until seven days after readmission from the hospital. During this period, multiple observations were made of the resident's feet and heels resting directly on the air mattress without offloading, despite care plans specifying the need for offloading and the use of positioning devices. The air mattress was also repeatedly set at incorrect weights, not matching the resident's actual weight. A new pressure injury was discovered on the resident's right lateral foot by the surveyor, which the facility was unaware of until it was pointed out during the survey. Staff interviews confirmed inconsistent practices regarding offloading and assessment of the resident's feet, and documentation of wound assessments was lacking for the period following readmission. Another resident, also with quadriplegia and at high risk for pressure injury development, was observed multiple times with heels resting directly on the mattress or pillows, not being properly offloaded. The care plan for this resident did not include specific interventions for offloading the heels or a repositioning schedule, and there was no documentation of refusal of offloading interventions. Staff interviews revealed a lack of clarity and consistency in implementing heel offloading, and the resident's family reported that repositioning was not consistently performed by staff. A third resident with a chronic stage 4 sacral pressure injury was hospitalized and readmitted on two separate occasions. In both instances, the facility did not complete a comprehensive assessment of the resident's pressure injury until two days after readmission. This delay in assessment was not in accordance with the facility's own policy, which requires comprehensive and timely wound assessments upon admission or readmission. The findings indicate that the facility did not ensure timely and thorough assessment, documentation, and implementation of individualized interventions to prevent the development or worsening of pressure injuries for residents at risk or with existing wounds.